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1st department of Obstetrics and Gynecology, Aristotle University of Thessaloniki, Greece and Infertility & IVF Center "Geniki Kliniki" Thessaloniki, Greece.
ABSTRACT
Tubal factor is still a common cause of female infertility, accounting for more than 40%. The results of tubal reconstructive surgery depend on the condition of tubal wall, the cause of the lesions, the length of follow-up as well as the woman’s age. The introduction of microsurgical techniques in the treatment of tubo-peritoneal infertility has significantly improved the pregnancy rates as compared to conventional macrosurgery. Laparoscopic surgery is associated with the same reproductive outcome but with less discomfort, shorter hospitalization and quicker resumption to normal activities since the laparotomy incision is avoided. The opportunity to overcome the disturbed tubal function by in vitro fertilization (IVF) raised the question about the treatment strategy in cases of tubal factor infertility. It seems that young patients with extensive destruction of the tubes or older women even with less severe tubal damage should be directed from the beginning to IVF. However, hydrosalpinges may have a negative impact on IVF outcome and salpingectomy prior to IVF seems to improve the chances of conception.
Key words: Tubal infertility, laparoscopic surgery, microsurgery, in vitro fertilization, hydrosalpinx, phimosis, adhesions.
Hysteroscopic endometrial ablation.
Ahmed Aboul Nasr, M.D.
Department of Gynecology and Obstetrics, Faculty of Medicine, Cairo University, Cairo, Egypt
ABSTRACT
Ablation of the endometrium for the treatment of dysfunctional uterine
bleeding is a relatively new technique in gynecology. The hysteroscope allowed
this transcervical approach using one of three main modalities namely Nd:YAG
laser, endometrial resection by electrosurgery or rollerball electrosurgery. The
main indication for endometrial ablation is heavy menstrual loss in the absence
of organic disease.
Most surgeons prefer to induce thinning of
the endometrium preoperatively by either GnRH-a or danazol. Amenorrhea or
reduced menstrual flow are considered as successful treatment outcome. This
varies in different studies and depends upon the used ablation technique, power
density, time of the device on tissue, preoperative preparation, age and
hormonal status of the patient population.
Endometrial
ablation performed by a competent hysteroscopist is associated with a high
degree of success and a low rate of complications. It is a reasonable
alternative to hysterectomy for the surgical management of menorrhagia. Proper
selection of patients and meticulous technique after adequate training are
mandatory.
Key words: Hysteroscopic endometrial ablation, endometrial laser ablation, rollerball electrosurgery, transcervical endometrial resection, dysfunctional uterine bleeding
Embryo cryopreservation.
Naim A. Abusheikha, MRCOG, Geoffrey C. Shaw, MRCOG
Aintree Center for reproductive Medicine, Liverpool, UK.
ABSTRACT
The first successful pregnancy after transfer of cryopreserved human embryo was described in 1983. The technique has rapidly been incorporated into most in-vitro fertilization (IVF) programs. While the advantages are evident there is little to cause concern regarding its safety. Supernumerary embryos can be frozen and used in subsequent cycles without ovarian hyperstimulation and it is possible to achieve pregnancy rates comparable to those resulting from fresh embryos. Most religiously- influenced ethicits accept that surplus embryos should be kept to assisst the infertile couples in future cycles. Previous studies have reported an increase in obstetric complications in pregnancies resulting from the transfer of frozen embryos. Recent evidence showed that there is no difference when compared with children conceived spontaneously. The incidence of birth defects is not affected by freezing and subsequent development of children appears normal. Nevertheless, emphasis is placed on long-term follow-up of children conceived from frozen embryos to allow further evaluation of growth, development and morbidity.
Development and enlargement of hydrosalpinges
during gonadotrophic stimulation for IVF/ET.
Karim H. I.
Abd-El-Maeboud, M.D.*, El-Sir El-Hussein, M.R.C.O.G., Essam Al-Dein M. Khalifa,
M.D.
Infertility and in vitro fertilization center, King Fahd Specialist Hospital, Buraidah, El-Qassim, Saudi Arabia.
ABSTRACT
Objective: To investigate the effect of gonadotropic stimulation for IVF on the sonographic evidence of hydrosalpinges.
Design: Retrospective study.
Setting: Governmental IVF Center.
Subjects and Methods: 321 women undergoing gonadotropic stimulation for IVF in 445 consecutive cycles. Those included 30 patients, in 47 cycles, with untreated mono- or bilateral hydrosalpinx. Transvaginal scanning (TVS) was used to perform a basal examination on cycle days 1 to 3, and ,later on, to monitor the response to gonadotropic stimulation.
Results: On basal examination, the sensitivity of TVS in diagnosing hydrosalpinx was 44.7% (21 out of 47 cycles). On repeated scanning, 7 hydrosalpinges, in 6 cycles, were found to be enlarged 2 to 4 days before ovum pick-up (OPU). Another 6 hydrosalpinges, in 6 cycles, were first seen late during late gonadotrophic stimulation and were noted to enlarge on repeated scanning.
Conclusion: On gonadotrophic stimulation for IVF/ET, hydrosalpinges may become evident and/or enlarged on transvaginal sonography (TVS) during late phase of ovulation induction. Balance between the tubal fluid secretion and drainage might explain the presence or the lack of enlargement or sonographic evidence of hydrosalpinges. The awareness of these sonographic findings of hydrosalpinges is important because of its implications on planning for and outcome of IVF/ET therapy.
Key Words: In vitro fertilization, infertility, hydrosalpinx.
Laparoscopic surgery for pelvic endometriosis
using Argon beam coagulation: preliminary experience.
Mohamed Zayed, M.D.
Department of Obstetrics and Gynecology, Cairo University, Cairo, Egypt.
ABSTRACT
Objective: To report our preliminary experience on the effectiveness of Argon beam coagulation; a new surgical tool in laparoscopic surgery for treatment of pelvic endometriosis.
Design: Prospective study.
Patients and Methods: Forty one patients with pelvic endometriosis were treated laparoscopically using argon beam coagulation (ABC) are presented in this study. Patients were classified into stage I (9 patients), stage II (11 patients), stage III (12 patients) and stage IV (9 patients) [American Fertility Society stages of endometriosis]. At initial laparoscopic surgery endometriotic implants were ablated using ABC. Adnexal and pelvic adhesions were scored and lysed. Patients were followed for a period of at least one year for improvement of pelvic pain, dysmenorrhea, occurrence of pregnancy and recurrence. Second look laparoscopy was performed 3-6 months postoperatively in patients with infertility and pelvic adhesions to assess results of surgical treatment and adhesiolysis procedure.
Results: Subjective improvement of pelvic pain and/or dysmenorrhea occurred in 75.86% of patients. Recurrence of pelvic endometriosis occurred in 12.19%. Four of these cases were stage III or IV disease. In three patients recurrence was limited to ovarian endometriomas. The mean adhesion score at second look laparoscopy in infertile patients (19 cases) was 9.4 (SD±3.6) compared with 15.7 (SD ± 3.1). The difference was statistically significant. Pregnancy occurred in 5 cases (17.8%), 3 of them had no adnexal adhesions at initial laparoscopic surgery.
Conclusion: Preliminary results have shown that ABC is a safe and effective new surgical tool for use in laparoscopic surgery for pelvic endometriosis. Further evaluation is however needed.
Effect of treatment of seminal viscosity
difficulties with a-chymotrypsin on the recovery of spermatozoa for assisted
reproductive technologies: comparisons between the SpermPrepTM filtration
and Percoll gradient centrifugation methods.
Panayiotis M.
Zavos, Ed.S., Ph.D.*, Panayota N. Zarmakoupis-Zavos, M.D., Juan R. Correa,
Ph.D.*
Andrology Institute of Lexington and Kentucky Center for Reproductive Medicine, Lexington, Kentucky
ABSTRACT
Objectives: The study was designed to assess the impact of limited proteolysis, using a-chymotrypsin in high viscosity semen specimens, on the qualitative and quantitative characteristics of spermatozoa recovered via the SpermPrep filtration and Percoll gradient centrifugation methods for possible use in assisted reproductive technologies (ART).
Design: Controlled clinical study.
Setting: Andrology Institute of Lexington.
Patients: Thirty patients producing high viscosity semen specimens, which otherwise were within normospermic limits, participated in this study.
Main Outcome Measures: Treatment of high viscosity semen specimens via limited proteolysis using a-chymotrypsin and preparation via the SpermPrepTM filtration or Percoll gradient centrifugation methods.
Results: The method of semen liquefaction as applied in this study aided in the recovery of greater numbers and higher quality spermatozoa (P<0.05) as compared to the conventional method. Improvements in all qualitative measurements assessed were noted between the conventional and the a-chymotrypsin liquefied specimens regardless of the sperm selection method employed.
Conclusions: The limited proteolysis of high viscosity semen specimens with a-chymotrypsin was shown to be a treatment which can assist significantly in the handling and preparation of human seminal specimens with viscosity difficulties. Furthermore, limited proteolysis of high viscosity semen specimens with a-chymotrypsin assisted in the recovery of greater numbers and higher quality spermatozoa which can be used further in the various assisted reproductive techniques.
Key words: Semen viscosity, proteolysis, coagulation, liquefaction, a-chymotrypsin
Does the choice of a luteal phase support
protocol influence the pregnancy rate after a controlled hormonal stimulation
using the long protocol?
Michael Ludwig, M.D., Ricardo
Felberbaum, M.D., Urda von Gizycki, M.D. Ottmar Bauer, M.D., Safaa
Al-Hasani, M.D., Klaus Diedrich, M.D.
Department of Obstetrics and Gynecology, Medical University of Lübeck,Lübeck, Germany
ABSTRACT
Objective: To prevent the onset of a severe OHSS (ovarian hyperstimulation syndrome) different protocols of luteal phase support depending on the estradiol value and the number of follicles are used in this study. In a high risk group, the patients receive 600 mg per day micronized progesterone intravaginally. If at least one high grade embryo is transferred in this high risk group, the patients additionally receive 5000 IU of hCG on day of embryo transfer. Otherwise the patients received three hCG injections.
Design: Reprospective study of 678 consecutive ICSI (intracytoplasmic sperm injection) cycles.
Setting: Infertility day clinic, Department of Gynecology and Obstetrics.
Patients: Six hundred and seventy eight cycles undergoing infertility treatment.
Main outcome measures: Differences in the pregnancy rate after the three different ways of luteal phase support.
Results: There was no difference between the groups regarding the mean age of the patients, the contribution of the different kinds of sterility, or the number of previous cycles. The implantation and pregnancy rates were low in the progesterone-only group. This may be due to either the protocol of luteal phase support - chosen as a consequence of a threatening OHSS and/or the lower rate of good quality oocytes received.
Conclusion: An injection of hCG on the day of embryo transfer in addition to the administration of progesterone in patients at risk of OHSS may increase the pregnancy rate. To exclude other variables from this analysis and to answer, whether there is really a benefit for these patients, a prospective, randomized study has to be done.
Key words: Ovarian hyperstimulation syndrome, intravaginal progesterone, human chorionic gonadotrophin, assisted reproductive technology.
Sperm immobilization - injection interval:
comparison of two microinjection techniques and impact on intracytoplasmic sperm
injection (ICSI) results.
Hassan Ali Hassan, M.D.*†‡, Omar
Khalil, M.D. †, Hisham Ali Saleh, M.D.*†, Iman Baghdady, M.D.*, Dalal
El-Gezeiry, M.D. *‡, Inas Ismaiel, B.Sc*
Miami IVF/ICSI Center, Alexandria, Egypt.
ABSTRACT
Objective: To compare two sperm immobilization-injector pipette loading-injection techniques.
Design: Prospective randomized study.
Setting: Miami IVF/ICSI center, Alexandria, Egypt. It is a private center.
Subjects: 728 oocytes were retrieved from 109
patients stimulated by a long agonist protocol and undergoing intracytoplasmic
sperm injection (ICSI) for severe male factor infertility in the period from
1/8/96 to 15/11/96.
Interventions: Oocytes were randomly
assigned to one of the following microinjection techniques: 1) Technique A
(Single loading technique): The number of motile sperm required for the
injection of the available oocytes were selected and immobilized. Thirty to
fifty minutes after immobilization all the required immobilized sperm were
loaded together in the microinjection pipette and oocytes were injected one
after the other using the loaded pipette. 2) Technique B (Multiple loading
technique): For every oocyte one motile sperm was selected, immobilized and
immediately used for oocyte microinjection. One sperm is loaded in the
injection pipette at a time.
Main Outcome Measures: Fertilization and cleavage
rates, and percentage of grade I or II embryos.
Results:
Technique B compared to technique A showed a significantly higher fertilization
and cleavage rates (62.4% versus 46.6%, and 84.3% versus 71.8%
respectively). The percentage of grade I or II embryos were comparable in
both techniques (71.8% versus 78% respectively).
Conclusion: Immobilization-injection interval and the technique of injector loading seem to be important variables that affect ICSI performance.
Key words: Intracytoplasmic sperm injection, sperm immobilization-injection interval, cytosolic factor.
Intravenous albumin combined with low dose
human chorionic gonadotropin and late step-down administration of menotropins
are effective in prevention of severe ovarian hyperstimulation syndrome in
high-risk patients in an in vitro fertilization program.
Ahmet Z. Isibyk, M.D., Osman Denizhan ?zgün, M.D., Semra Kahraman,
M.D., Gurur Polat, M.D., Kubilay Vicdan, M.D., Kutay Biberoglu, M.D., Levent
Alaybeyoglu, M.D.
Sevgi Hospital, ART Center, Ankara, Turkey
ABSTRACT
Objective: To study the effect of intravenous albumin combined with low dose human chorionic gonadotrophin and late step-down administration of menotropins on the prevention of ovarian hyperstimulation syndrome.
Materials and Methods: Ninety three high risk patients with an E2 level >20000 pmol/l on the day of hCG day were followed by serial ultrasonographic examinations and complete blood count analysis after embryo transfer until the day of pregnancy test. All the patients received long GnRHa/HMG protocol. Patients were administered 5000 IU HCG for ovulation triggering and 20 grams 100 cc intravenous albumin at the retrieval day. In addition to this, dose of HMG was reduced in the last few days of the ovulation induction if E2 levels tended to reach the cut off point.
Results: The level of estradiol on the day of hCG was 26171.06 ± 4332.04 pmol/l. No patients developed severe OHSS. In 4 patients moderate OHSS occurred, they were hospitalized only for a few days. Two of them were pregnant. A control group of 313 patients were treated during the same period and had a mean E2 level of 10508 ± 2835.6 pmol/l, and two patients developed severe and 7 patients developed moderate ovarian hyperstimulation syndrome. Both of the severe and one of the moderate OHSS patients were pregnant. The overall pregnancy rate of 406 cycles per retrieval dthe same time period was 29.2 % and this rate in the high risk group was 31.18 %.
Conclusion: Intravenous albumin combined with low dose hCG and late step-down administration of menotropins proved to be effective in the prevention of severe ovarian hyperstimulation syndrome.
Key words: OHSS, HCG, Albumin, HMG, Coasting, IVF
Secondary infertility in women with one
previous Cesarean Section: anatomicopathological study.
Azmi E. S. Abdrabo, M.R.C.O.G.*, Firdos Sheik, M.D. ‡, Tarek A. Abdel
Hamid, Ph .D. †
Heraa General Hospital, Makkah, Saudi Arabia.
ABSTRACT
Objective: To study morbid anatomy of the pelvis in women with secondary infertility who had delivered once by cesarean section (CS).
Design: retrospective study.
Setting: Teaching Hospital Ministry of Health, Makkah, Saudi Arabia.
Patients: 40 patients with secondary infertility ,
40 fertile patients with one previous CS and 40 patients with secondary
infertility after vaginal delivery. The three groups were of the same age and
race.
Interventions: Pelvic ultrasound scan,
Hysterosalpingography (HSG), Hysteroscopy and Laparoscopy. Day 3 hormonal
profile: follicle stimulating hormone (FSH), luteinizing hormone (LH),
Prolactin, Estradiol, testosterone, Thyroid stimulating hormone (TSH) and luteal
phase progesterone assay.
Main outcome measures: morbid anatomy of cervix, uterus, tubes, ovaries, and pelvic peritoneum.
Results: The uterus was found adherent to the abdominal wall with limited mobility in 20 cases (50%) compared to 5 cases in control group 1. 5 cases had high ovarian position. Short cervix ( less than 2 cm) was present in 5 cases and the anterior lip of the cervix was absent in 3 cases. Cervix to uterus ratio was increased in 3 cases. There were 10 cases of tubal block of whom 7 cases were bilateral .Control group 2 included 6 cases of tubal block of whom 4 were bilateral. Moderate tubo-ovarian adhesions were present in 9 cases compared to 2 cases of mild adhesions in both control group 1 and control group 2. There were 3 cases of hydrosalpinges, and two cases of frozen pelvis in the study group. In addition, there were two cases of severe intrauterine synaechia , one case of endometritis and two cases of vesico-uterine fistula.
Conclusion: This study demonstrates that patients with secondary infertility and a history of previous one cesarean section, may have significant pelvic abnormalities and these women should be screened for such abnormalities prior to their infertility therapy.
Key Words: Cesarean Section, Adhesions, morbid anatomy, vesicouterine fistula, intrauterine adhesions.